HISTORIA CLINICA Cirugia
HISTORIA CLINICA Cirugia
HISTORIA CLINICA Cirugia
I. ANAMNESIS
Datos de Filiacin:
Nombre y Ap.:________________________________________________
Fecha de Nacimiento:_____________________________
Lugar de Nacimiento:_____________________________
Edad:________________
Sexo:________________
Grado de Instruccin:___________________
Profesin u Ocupacin:__________________________________
Estado Civil:__________________________
Domicilio:____________________ Localidad:_______________
Telfono:__________________ D.N.I:_______________
Fecha de Ingreso:________________________________
Tiempo de la Enfermedad:_____________________________
Forma de Inicio:____________________________________
Curso de la Enfermedad:______________________________
III.1
ANTECEDENTES GINECOOBSTETRICOS
Menarqua:________________________
Rgimen Coterminal:_________________
Menopausia:_______________________
Formula Obsttrica:
III.2
ANTECEDENTES PATOLOGICOS
Enfermedades Sistmicas:______________________
Enfermedades Sanguneas:_____________________
IV.1
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IV.1.1
Ectoscopia:
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IV.1.2
Signos Vitales
Pulso:_____________________
Presin Arterial:___________________
IV.2
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Crneo:
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Cara:
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ENDOBUCAL
Enca:
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V. EXAMENES AUXILIARES
V.1
Exmenes de Laboratorio:
V.1.1
Tiempo de Sangra:_____________________
V.1.2
Tiempo de Coagulacin:__________________
VI.1
Diagnostico Presuntivo:
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VI.2
Diagnostico Definitivo:
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VII. PRONOSTICO:
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VIII. PLAN DE TRATAMIENTO:
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IX. EPICRISIS
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Fecha:
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Firma: